Systemic anti-inflammatory treatment of atopic dermatitis during conception, pregnancy and breastfeeding: Interdisciplinary expert consensus in Northern Europe

Treating atopic dermatitis (AD) in pregnant or breastfeeding women, and in women and men with AD aspiring to be parents is difficult and characterized by uncertainty, as evidence to inform decision-making on systemic anti-inflammatory treatment is limited. This project mapped consensus across dermatologists, obstetricians and patients in Northwestern Europe to build practical advice for managing AD with systemic anti-inflammatory treatment in men and women of reproductive age. Twenty-one individuals (sixteen dermatologists, two obstetricians and three patients) participated in a two-round Delphi process. Full consensus was reached on 32 statements, partial consensus on four statements and no consensus on four statements. Cyclosporine A was the first-choice long-term systemic AD treatment for women preconception, during pregnancy and when breastfeeding, with short-course prednisolone for flare management. No consensus was reached on second-choice systemics preconception or during pregnancy, although during breastfeeding dupilumab and azathioprine were deemed suitable. It may be appropriate to discuss continuing an existing systemic AD medication with a woman if it provides good disease control and its benefits in pregnancy outweigh its risks. Janus kinase (JAK) inhibitors, methotrexate and mycophenolate mofetil should be avoided by women during preconception, pregnancy and breastfeeding, with medication-specific washout periods advised. For men preconception: cyclosporine A, azathioprine, dupilumab and corticosteroids are appropriate; a 3-month washout prior to conception is desirable for methotrexate and mycophenolate mofetil; there was no consensus on JAK inhibitors. Patient and clinician education on appropriate (and inappropriate) AD treatments for use in pregnancy is vital. A shared-care framework for interdisciplinary management of AD patients is advocated and outlined. This consensus provides interdisciplinary clinical guidance to clinicians who care for patients with AD before, during and after pregnancy. While systemic AD medications are used uncommonly in this patient group, considerations in this article may help patients with severe refractory AD.

ATP1A3 related disease manifesting as rapid onset dystonia-parkinsonism with prominent myoclonus and exaggerated startle

We report ATP1A3-associated rapid-onset dystonia-parkinsonism with an atypical presentation including myoclonus and exaggerated startle in four patients. Their prominence over parkinsonism prompted consideration of a syndromic diagnosis of myoclonus dystonia. ATP1α3 dysfunction in GABAergic neurons could explain these examination findings. The spectrum of ATP1A3-associated movement disorders includes myoclonus-dystonia.

Moving into the red - a near infra-red optical probe for analysis of human neutrophil elastase in activated neutrophils and neutrophil extracellular traps

Neutrophils are the first immune cells recruited for defence against invading pathogens; however, their dysregulated activation and subsequent release of the enzyme human neutrophil elastase is associated with several, inflammation-based, diseases. Herein, we describe a FRET-based, tri-branched (one quencher, three fluorophores) near infrared probe that provides an intense OFF/ON amplified fluorescence signal for specific detection of human neutrophil elastase. The probe allowed selective detection of activated neutrophils and labelling of neutrophil extracellular traps.

Military experience in the management of pelvic fractures from OIF/OEF

INTRODUCTION

Pelvic fractures are a common occurrence in combat trauma. However, the fracture pattern and management within the most recent conflicts, i.e. Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF), have yet to be described, especially in the context of dismounted complex blast injury. Our goal was to identify the incidence, patterns of injury and management of pelvic fractures.

METHODS

We conducted a retrospective review on all combat-injured patients who arrived at our military treatment hospital between November 2010 and November 2012. Basic demographics, Young-Burgess fracture pattern classification and treatment strategies were examined.

RESULTS

Of 562 patients identified within the study time period, 14% (81 of 562) were found to have a pelvic fracture. The vast majority (85%) were secondary to an improvised explosive device. The average Injury Severity Score for patients with pelvic fracture was 31±12 and 70% were classified as open. Of the 228 patients with any traumatic lower extremity amputation, 23% had pelvic fractures, while 30% of patients with bilateral above-knee amputations also sustained a pelvic fracture. The most common Young-Burgess injury pattern was anteroposterior compression (APC) (57%), followed by lateral compression (LC) (36%) and vertical shear (VS) (7%). Only 2% (nine of 562) of all patients were recorded as having pelvic binders placed in the prehospital setting. 49% of patients with pelvic fracture required procedural therapy, the most common of which was placement of a pelvic external fixator (34 of 40; 85%), followed by preperitoneal packing (16 of 40; 40%) and angioembolisation (three of 40; 0.75%). 17 (42.5%) patients required combinations of these three treatment modalities, the majority of which were a combination of external fixator and preperitoneal packing. The likelihood to need procedural therapy was impacted by injury pattern, as 72% of patients with an APC injury, 100% of patients with a VS injury and 25% of patients with an LC injury required procedural therapy.

CONCLUSIONS

Pelvic fractures were common concomitant injuries following blast-induced traumatic lower extremity amputations. APC was the most common pelvic fracture pattern identified. While procedural therapy was frequent, the majority of patients underwent conservative therapy. However, placement of an external fixator was the most frequently used modality. Considering angioembolisation was used in less than 1% of cases, in the forward deployed military environment, management should focus on pelvic external fixation±preperitoneal packing. Finally, prehospital pelvic binder application may be an area for further process improvement.

Restoration of marine ecosystems: Understanding possible futures for optimal outcomes

Accelerating declines in the extent, quality and functioning of the world's marine ecosystems have generated an upsurge in focus on practical solutions, with ecosystem restoration becoming an increasingly attractive mitigation strategy for systems as diverse as coral reefs, mangroves and tidal flats. While restoration is popular because it promises positive outcomes and a return to something approaching unimpacted condition and functioning, it involves substantial public and private investment, both for the initial restoration activity and for on-going maintenance of the restored asset. This investment often affords one big chance to get things right before irretrievable damage is done. As a result, precise, well considered and accountable decision-making is needed to determine the specific focus for restoration, the scale of restoration, the location for deploying restoration activities, and indeed whether or not restoration is necessary or even possible. We explore the environmental/ecological considerations and constraints governing optimal decisions about the nature, location and prioritisation of restoration activities in marine ecosystems, and in particular the constraints on achieving understanding of possible futures and the likelihood of achieving them. We conclude that action must be informed by a context-specific understanding of the historical situation, the current situation, the constraints on change, the range of potential outcome scenarios, and the potential futures envisioned.

Filaggrin mutations in relation to skin barrier and atopic dermatitis in early infancy

BACKGROUND

Loss-of-function mutations in the skin barrier gene filaggrin (FLG) increase the risk of atopic dermatitis (AD), but their role in skin barrier function, dry skin and eczema in infancy is unclear.

OBJECTIVES

To determine the role of FLG mutations for impaired skin barrier function, dry skin, eczema and AD at three months of age and through infancy.

METHODS

FLG mutations were analyzed in 1836 infants in the Scandinavian population-based PreventADALL study. Transepidermal water loss (TEWL), dry skin, eczema and AD were assessed at three, six and 12 months of age.

RESULTS

Filaggrin mutations were observed in 166 (9%) infants. At three months, carrying FLG mutations was not associated with impaired skin barrier function (TEWL > 11.3 g/m² /h) or dry skin, but with eczema (OR(95%CI): 2.76 (1.81, 4.23), p < 0.001). At six months, mutation carriers had significantly higher TEWL than non-mutation carriers (mean (95%CI) 9.68 (8.69, 10.68) vs. 8.24 (7.97, 8.15), p < 0.01) and at three and six months an increased risk of dry skin on truncus (OR: 1.87 (1.25, 2.80), p = 0.002; 2.44 (1.51, 3.95), p < 0.001) or extensor limb surfaces (1.52 (1.04, 2.22), p = 0.028; 1.74 (1.17, 2.57), p = 0.005). FLG mutations were associated with eczema and AD in infancy.

CONCLUSION

Filaggrin mutations were not associated with impaired skin barrier function or dry skin in general at three months of age, but increased the risk for eczema, as well as for dry skin on truncus and extensors at three and six months.

Water height modifies forelimb kinematics of horses during water treadmill exercise

Although equine water treadmills (WTs) are increasingly being used for the rehabilitation of equine athletes, the immediate- and short-term effects of this type of exercise on limb movement in the WT and overground are unknown. Therefore, the objective of this study was to evaluate the effects of WT exercise on equine forelimb kinematics on land and under various WT conditions before and after a prolonged period of WT conditioning. External markers were used to collect 2D kinematic data (joint extension, flexion, range of motion (ROM), elevation; stride mechanics) at 120 frames/s. Thirteen mixed breed, English performance horses were filmed under three test conditions: (1) horses walked on sand; (2) horses walked on a WT (water heights: dry, carpus, stifle); (3) horses walked on sand immediately following a WT session. Walking speeds during testing varied between horses, ranging from 1.3-1.5 m/s, but were held constant for each individual horse for all tests on both days. Testing occurred on days 1 and 10, with horses being trained on the WT for days 2 through 8 (28 min/day). Comparisons were made using linear mixed effects models. Carpal ROM and elbow ROM were greater when horses were walked in water, compared to without water (dry treadmill) and overground (P<0.0001 for all). This increased ROM was achieved primarily via an increase in joint flexion. With the addition of water, stride length increased and stride frequency decreased, accompanied by an increased percentage duration of swing phase. No effects of conditioning on gait mechanics were observed overground. Therefore, WT exercise may be meaningful for physical rehabilitation through increased joint flexion and ROM observed.

Association between atopic dermatitis and autoimmune diseases: a population-based case-control study

Background

Atopic dermatitis (AD) is a common chronic skin disorder and is well known to be associated with other atopic conditions. There is increasing evidence for an association also with nonatopic conditions, including autoimmune diseases, but data are limited about several autoimmune diagnoses.

Objectives

To investigate the association between AD and autoimmune diseases.

Methods

This case–control study used Swedish national healthcare registers. The source population comprised the entire Swedish population aged ≥ 15 years from 1968 to 2016. Cases, including all those with an inpatient diagnosis of AD (from 1968) and/or a specialist outpatient diagnosis of AD (from 2001), were matched by sex and age to healthy controls (104 832 cases of AD, 1 022 435 controls).

Results

AD was significantly associated with one or more autoimmune diseases compared with controls – adjusted odds ratio (aOR) 1·97, 95% confidence interval (CI) 1·93–2·01 – and this association was significantly stronger in the presence of multiple autoimmune diseases compared with only one. The association was strongest for autoimmune disorders involving the skin (aOR 3·10, 95% CI 3·02–3·18), the gastrointestinal tract (aOR 1·75, 95% CI 1·69–1·82) or connective tissue (aOR 1·50, 95% CI 1·42–1·58). In the overall analysis, men with AD had a stronger association with rheumatoid arthritis and coeliac disease than did women with AD. In subanalyses, the findings remained stable in multivariable analyses after adjustment for smoking and parental autoimmune disease.

Conclusions

This large population‐based study indicates significant autoimmune comorbidity of adults with AD, especially between AD and autoimmune dermatological, gastrointestinal and rheumatological diseases. Having multiple autoimmune diseases resulted in a stronger association with AD than having only one autoimmune disease.

What is already known about this topic?

Atopic dermatitis (AD) is one of the most common chronic inflammatory skin diseases.

Some studies have shown that AD is associated with some autoimmune diseases, such as Crohn disease, ulcerative colitis, coeliac disease, alopecia areata and vitiligo, but data are limited for several major autoimmune diagnoses.

What does this study add?

In this study, AD was associated with several autoimmune diseases, especially those involving the skin, the gastrointestinal tract or connective tissue.

The association was stronger for individuals with multiple autoimmune comorbidities.

Linked Comment: J.I. Silverberg. Br J Dermatol 2021; 185:243–244.

Plain language summary available online

Comparison of a Radiant Patient Warming Device with Forced Air Warming during Laparoscopic Cholecystectomy

The importance of maintaining a patient's core body temperature during anaesthesia to reduce the incidence of postoperative complications has been well documented. The standard practice of this institution is the use of a forced air device for intraoperative warming. The purpose of this study was to compare this standard with an alternative warming device using a radiant heat source which only heated the face.

This prospective, randomized controlled trial compared the efficacy of two methods of intraoperative warming: the BairHugger™ (Augustine Medical, U.S.A.) forced air device and the SunTouch™ (Fisher & Paykel Healthcare, N.Z.) radiant warmer during laparoscopic cholecystectomy in 42 female patients. Oesophageal core temperatures were recorded automatically on to computer during operations using standardised anaesthesia, intravenous infusions and draping.

The study failed to show any statistical or clinical difference between the two patient groups in terms of mean core temperature both intraoperatively (P=0.42) and in the recovery period (P=0.54). Mean start to end core temperature differences were marginly lower in the radiant group (0.08°C) but not statistically or clinically significantly different.

Given some of the drawbacks with forced air systems, such as the expense of the single use blanket, this new radiant warming device offers an alternative method of active warming with advantages in terms of cost and possible application to a wide variety of surgical procedures.

Urban foodscape trends: Disparities in healthy food access in Chicago, 2007-2014

We investigated changes in supermarket access in Chicago between 2007 and 2014, spanning The Great Recession, which we hypothesized worsened local food inequity. We mapped the average street network distance to the nearest supermarket across census tracts in 2007, 2011, and 2014, and identified spatial clusters of persistently low, high or changing access over time. Although the total number of supermarkets increased city-wide, extremely low food access areas in segregated, low income regions did not benefit. Among black and socioeconomically disadvantaged residents of Chicago, access to healthy food is persistently poor and worsened in some areas following recent economic shocks.

Ballistic and snake photon imaging for locating optical endomicroscopy fibres

We demonstrate determination of the location of the distal-end of a fibre-optic device deep in tissue through the imaging of ballistic and snake photons using a time resolved single-photon detector array. The fibre was imaged with centimetre resolution, within clinically relevant settings and models. This technique can overcome the limitations imposed by tissue scattering in optically determining the in vivo location of fibre-optic medical instruments.

Time-resolved spectroscopy at 19,000 lines per second using a CMOS SPAD line array enables advanced biophotonics applications

A SPAD-based line sensor fabricated in 130 nm CMOS technology capable of acquiring time-resolved fluorescence spectra (TRFS) in 8.3 milliseconds is presented. To the best of our knowledge, this is the fastest time correlated single photon counting (TCSPC) TRFS acquisition reported to date. The line sensor is an upgrade to our prior work and incorporates: i) parallelized interface from sensor to surrounding circuitry enabling high line rate to the PC (19,000 lines/s) and ii) novel time-gating architecture where detected photons in the OFF region are rejected digitally after the output stage of the SPAD. The time-gating architecture was chosen to avoid electrical transients on the SPAD high voltage supplies when gating is achieved by excess bias modulation. The time-gate has an adjustable location and time window width allowing the user to focus on time-events of interest. On-chip integrated center-of-mass (CMM) calculations provide efficient acquisition of photon arrivals and direct lifetime estimation of fluorescence decays. Furthermore, any of the SPC, TCSPC and on-chip CMM modes can be used in conjunction with the time-gating. The higher readout rate and versatile architecture greatly empower the user and will allow widespread applications across many techniques and disciplines. Here we focused on 3 examples of TRFS and time-gated Raman spectroscopy: i) kinetics of chlorophyll A fluorescence from an intact leaf; ii) kinetics of a thrombin biosensor FRET probe from quenched to fluorescence states; iii) ex vivo mouse lung tissue autofluorescence TRFS; iv) time-gated Raman spectroscopy of toluene at 3056 cm^-1 peak. To the best of our knowledge, we detect spectrally for the first time the fast rise in fluorescence lifetime of chlorophyll A in a measurement over single fluorescent transient.

Endoscopic sensing of alveolar pH

Previously unobtainable measurements of alveolar pH were obtained using an endoscope-deployable optrode. The pH sensing was achieved using functionalized gold nanoshell sensors and surface enhanced Raman spectroscopy (SERS). The optrode consisted of an asymmetric dual-core optical fiber designed for spatially separating the optical pump delivery and signal collection, in order to circumvent the unwanted Raman signal generated within the fiber. Using this approach, we demonstrate a ~100-fold increase in SERS signal-to-fiber background ratio, and demonstrate multiple site pH sensing with a measurement accuracy of ± 0.07 pH units in the respiratory acini of an ex vivo ovine lung model. We also demonstrate that alveolar pH changes in response to ventilation.

Inducible LAP-tagged Stable Cell Lines for Investigating Protein Function, Spatiotemporal Localization and Protein Interaction Networks

Multi-protein complexes, rather than single proteins acting in isolation, often govern molecular pathways regulating cellular homeostasis. Based on this principle, the purification of critical proteins required for the functioning of these pathways along with their native interacting partners has not only allowed the mapping of the protein constituents of these pathways, but has also provided a deeper understanding of how these proteins coordinate to regulate these pathways. Within this context, understanding a protein's spatiotemporal localization and its protein-protein interaction network can aid in defining its role within a pathway, as well as how its misregulation may lead to disease pathogenesis. To address this need, several approaches for protein purification such as tandem affinity purification (TAP) and localization and affinity purification (LAP) have been designed and used successfully. Nevertheless, in order to apply these approaches to pathway-scale proteomic analyses, these strategies must be supplemented with modern technological developments in cloning and mammalian stable cell line generation. Here, we describe a method for generating LAP-tagged human inducible stable cell lines for investigating protein subcellular localization and protein-protein interaction networks. This approach has been successfully applied to the dissection of multiple cellular pathways including cell division and is compatible with high-throughput proteomic analyses.

Acute skin and hair symptoms followed by severe, delayed eye complications in subjects using the synthetic opioid MT-45

BACKGROUND

The introduction of unclassified new psychoactive substances (NPS) on the recreational drugs market through open online sale ('legal highs' or 'Internet drugs') continues unabated and represents a growing health hazard. The use of NPS has resulted in numerous, severe, adverse events and fatalities, due to unintended overdose or unknown toxic side-effects.

OBJECTIVES

To try to find a possible common underlying cause for the skin-hair-eye symptoms complex observed in three men.

METHODS

From late 2013 to mid-2014, three Swedish men aged 23-34 years with a history of recreational drug use independently presented with similar and very remarkable clinical signs, requiring extensive examination and prolonged treatment.

RESULTS

Common clinical signs included hair depigmentation, hair loss, widespread folliculitis and dermatitis, painful intertriginous dermatitis, dry eyes, and elevated liver enzymes. Two of them also showed transverse white Mees' lines (leukonychia striata) on the fingernails and toenails, suggesting a temporary, drug-induced, disorganized keratinization. The clinical signs gradually disappeared over time. However, later on, two developed severe bilateral secondary cataracts requiring surgery. Because drug tests within the Swedish STRIDA project had demonstrated intake of the NPS opioid MT-45 in all patients, this was suspected to be the common causative agent.

CONCLUSIONS

These cases highlight the importance for physicians and health professionals to consider the increasing number of novel, untested recreational drugs, as a potential cause of unusual and otherwise unrecognized clinical signs and symptoms.

Majocchis Granuloma Caused by Trichophyton mentagrophytes in 2 Immunocompetent Patients

Majocchi granuloma is an uncommon deep follicular inflammation caused by dermatophytes and affects immunocompetent and immunocompromised patients. The clinical findings overlap with other skin conditions such bacterial infections and inflammatory skin diseases, thereby delaying correct diagnosis. We describe 2 cases in immunocompetent patients.

The discovery of potent, orally bioavailable pyrimidine-5-carbonitrile-6-alkyl CXCR2 receptor antagonists

A hit-to-lead optimisation programme was carried out on the Novartis archive screening hit, pyrimidine 2-((2,6-dichlorobenzyl)thio)-5-isocyano-6-phenylpyrimidin-4-ol 4, resulting in the discovery of CXCR2 receptor antagonist 2-((2,3-difluorobenzyl)thio)-6-(2-(hydroxymethyl)cyclopropyl)-5-isocyanopyrimidin-4-ol 24. The SAR was investigated by systematic variation of the aromatic group at c-6, the linker between c-2 and the halogenated ring, and the c-5 nitrile moiety.

Moisturizing treatment of patients with atopic dermatitis and ichthyosis vulgaris improves dry skin, but has a modest effect on gene expression regardless of FLG genotype

BACKGROUND

Loss-of-function mutations in FLG (encoding filaggrin) are a predisposing factor for atopic dermatitis (AD) and cause ichthyosis vulgaris (IV). Patients with AD and IV display impaired skin barrier and dry skin, and altered epidermal expression of genes in pro-inflammatory and lipid metabolic pathways are often evident.

OBJECTIVES

To evaluate the effect of three different moisturizers on skin barrier function and epidermal gene expression in patients with AD/IV in relation to FLG mutation status.

METHODS

Patients (n = 43) were classified according to their FLG status: AD with FLG+/+ (n = 14), AD with FLG+/- (n = 14), and AD/IV with FLG-/- (n = 15). Dryness score and transepidermal water loss (TEWL) were monitored on volar forearms, and punch biopsies were taken for analysis of gene expression. Measurements were repeated after 4 weeks of treatment with either of two moisturizers on each forearm.

RESULTS

Treatment with any of the three moisturizers significantly reduced dryness score and TEWL in the group as a whole. FLG-/- patients displayed the largest reduction in dryness score. Only minute changes occurred in the mRNA expression of 15 selected epidermal genes.

CONCLUSIONS

Moisturizing treatment improves dry skin and certain aspects of abnormal skin barrier function, especially in patients with AD/IV and dual FLG mutations, but does not normalize the epidermal gene expression profile.

The discovery of potent, orally bioavailable pyrazolo and triazolopyrimidine CXCR2 receptor antagonists

A hit-to-lead optimisation programme was carried out on the Novartis archive screening hit, pyrazolopyrimidine 2-methyl-5-((phenylthio)methyl)pyrazolo[1,5-a]pyrimidin-7-ol 1, resulting in the discovery of CXCR2 receptor antagonist 2-benzyl-5-(((2,3-difluorophenyl)thio)methyl)-[1,2,4]triazolo[1,5-a]pyrimidin-7-ol 14. The SAR was investigated by systematic variation of the pendant thiol, alkyl and pyrimidinol groups. Replacement of the pyrazolopyrimidine core with a triazolo alternative led to a dual series of antagonists with favourable biological and pharmacokinetic properties.

The clinical utility of HIV outpatient pharmacist prescreening to reduce medication error and assess adherence

Antiretroviral therapy (ART) is complex and has high propensity for medication error and drug-drug interactions (DDIs). We evaluated the clinical utility of pharmacist prescreening for DDIs, adherence to ART and medicines reconciliation prior to HIV outpatient appointments. A pharmacist took detailed medication histories and ART adherence assessments, then screened medication for DDIs. A template detailing current medication, potential DDIs and adherence was filed in the clinical notes and physicians were asked for structured feedback. Potential DDIs were observed in 58% of 200 patients, with 22 (9%) potential DDIs occurring with medication that was not previously recorded in the patients’ notes. Of 103 physician responses, 61.2% reported that the pharmacist consultation told them something they did not know, and pharmacist consultants led to change in management in 13.6% of cases. Pharmacist consultations were more likely to add benefit in patients taking two or more concomitant medications in addition to ART ( P = 0.0012).

Long-term survival after treatment for Hodgkin's disease (1973-2002): improved survival with successive 10-year cohorts

Background:

The Nottinghamshire Lymphoma Registry contains the details of all the patients diagnosed with lymphoma (since 1 January 1973) within a defined geographical area with a population of 1.1 million. It was therefore possible to study the outcome of treatment for Hodgkin’s disease for three 10-year cohorts (1973–1982, 1983–1992 and 1993–2002).

The aims of the study were to compare survival time among the three patient cohorts, to identify prognostic factors and to estimate relative survival.

Methods:

A total of 745 patients diagnosed between 1973 and 2002 were analysed for survival. Survivorship was estimated by the Kaplan-Meier method and parametric survival models. An accelerated failure-time regression was used for multivariate analysis.

Results:

Overall, patients were observed for 9.8 (0.3–34.82) years (median(range)), on average. One, five and fifteen-year disease-specific survival was found to be 87% (85–90%), 77% (74–80%) and 70% (67–74%), respectively. For those for diagnosed between 1973 and 1982, the 15-year survival was found to be 57% for 1983–1992, it was 74% and for 1993–2002, it was 83% (P<0.001). The difference remained significant after adjusting for prognostic factors. The actuarial risk of developing a second malignancy at 20 years was for the 1973–1982 cohort, 12.4%, and for the 1983–1992 cohort, 18.8%.

Conclusion:

Treatment advances and effective management of toxicities of treatment over time, have resulted in a significantly longer survival for patients with Hodgkin’s disease diagnosed within a defined population.

Results of screening for intracranial aneurysms in patients with coarctation of the aorta

BACKGROUND AND PURPOSE

IAs are found in 2.3% of adults; the mean age at detection is 52 years. Prevalence is <0.5% in young adults. Early studies suggest that 10%-50% of patients with aortic coarctation have IAs. Screening recommendations are variable. We sought to examine the prevalence of IAs through screening with MRA.

MATERIALS AND METHODS

Consecutive patients older than 16 years of age with coarctation undergoing brain MRA between May 1999 and October 2007 were included. MRA was performed by using a 1.5T scanner with a 3D time-of-flight protocol; simultaneous MR imaging was performed of the heart and aorta. Cerebral MRAs were double-reported by a neuroradiologist. Statistics are described as mean ± SD and median ± range. Continuous variables were compared by using Student t tests and Mann-Whitney U tests (categoric variables, by using the Fisher exact test).

RESULTS

One hundred seventeen MRAs were double-reported. The median age was 29 ± 11 years (range, 16-59 years). IAs were found in 12 patients (10.3%). The mean diameter of IAs was 3.9 mm (range, 2.0-8.0 mm). Patients with aneurysms were older (median, 37 years; range, 16-50 years) than those without (median, 23 years; range, 16-59 years; Z = -2.01, P = .04). Hypertension was more common in those with IAs (IA 83% versus no IA 43%, P = .01). There was no association between ascending aortopathy, bicuspid aortic valves, and IAs.

CONCLUSIONS

Patients with coarctation have a higher prevalence of IAs, occurring at an earlier age than in population studies. Whether routine screening is appropriate for this group of patients is unclear. Hypertension is likely to be an important pathophysiologic factor.

Patients accessing HIV treatment via sexual health services: what are the risks of the dual case-note system?

In many British hospitals, HIV-positive patients access care via genitourinary (GU) medicine services. As a result of National Health Service (NHS) legislation, such patients may have information concerning HIV treatment filed separately from their general clinical records. We sought to evaluate accuracy of medication records of patients with both GU medicine and general hospital case-notes, and to assess clinical risk arising from incorrect or incomplete recording. In this retrospective review, 156 episodes of care from 100 HIV-positive patients with separate HIV case-notes were evaluated for accuracy of medication recording, when paired with clinical notes from attendances in other hospital departments. Discrepancies were observed in 52.6% of care episodes; significant discrepancies were apparent in 7.8%. The dual case-note system represents significant risk to patient care. We recommend that hospitals that continue to operate this system urgently consider amalgamation of HIV care records into hospital case sheets, in line with current national standards.

An unusual haematological presentation of the immune reconstitution inflammatory syndrome

We describe the case of a newly diagnosed HIV-1-positive man who was noted to have asymptomatic HIV-related idiopathic (immune) thrombocytopaenic purpura. On commencing antiretroviral therapy we believe he experienced an uncommon immune reconstitution phenomenon resulting in the rapid worsening of his thrombocytopenia, requiring steroid therapy which stabilized his platelet levels.

Lack of association between filaggrin gene mutations and onset of psoriasis in childhood

BACKGROUND

Atopic dermatitis (AD; OMIM#603165) and psoriasis (OMIM#177900) are two common inflammatory skin disorders. Both are genetically complex, multifactorial and do not follow a Mendelian pattern of inheritance. Both diseases share several genetic susceptibility loci such as the epidermal differentiation complex (EDC) on chromosome 1q21. Within the EDC, mutations in the filaggrin (FLG) gene are strongly associated with AD whereas no association has been replicated with psoriasis. However, reduced levels of filaggrin have been reported in psoriatic skin. Further, filaggrin deficiency was shown to be a modifying factor for the phenotype in another epidermal skin disorder, X-linked recessive ichthyosis. Altogether, this raises the question if FLG mutations may modify the disease course in other epidermal skin diseases such as psoriasis. Psoriasis is a highly heterogeneous disease and so far genetic studies have not taken the distinct sub-phenotype childhood onset into account.

OBJECTIVE

To determine if FLG mutations modify the onset of psoriasis.

MATERIALS AND METHODS

A total of 241 children with onset of psoriasis below 15 years of age and 314 healthy controls were identified at the Dermatology clinic, Karolinska University Hospital and diagnosed by the same dermatologist (JL). Blood samples were taken and medical history was recorded. FLG was genotyped in all patients and controls using allelic discrimination (n = 555) and sequencing (n = 20).

RESULTS AND CONCLUSIONS

No association between FLG mutations and early onset of psoriasis was demonstrated (P = 0.57) and no novel mutations were detected, indicating that FLG loss-of-function variants do not have a strong effect on the onset of psoriasis in childhood.